Palliative Care, Pain Control, & End-of-Life Care

1. Background/Cultural Points:

   Good pain control, end-of-life, and palliative care is generally deficient in Cambodia, as in many poorer countries, as is access to opioids. MMC patients with cancers, end-stage liver disease, and other conditions may be prescribed palliative/comfort care and family members may return to MMC for refills if the patient is too unwell to travel. This approach also avoids risking end-of-life patients dying in Phnom Penh away from home, which, due to cultural-religious issues, can be extra disturbing to many Cambodians. Hospice care may be available at NLF’s “Healing Home” in Phnom Penh.

2. Common Pain Management & Other

• Give only one drug from the opioid and non-opioid group at a time

1. WHO Analgesic Ladder adaptation for MMC:

   1. Step 1: Paracetamol (Acetaminophen) or NSAIDs (Ibuprofen is preferred, with 200 and 400mg tabs available)
   2. Step 2: Higher dose NSAID or Para+Codeine
   3. Step 3: Tramadol (Morphine Sulfate in exceptional situations)

2. Opioids are limited:

   1. Paracetamol + Codeine is available in two quantities: 500mg Para with 8mg Codeine or 500mg Para with 30mg Codeine. 500/8 is significantly cheaper than 500/30.
   2. No oral opioids are otherwise available (hydrocodone, oxycodone, etc)
   3. Morphine IM/IV may be available in limited quantity for use in OPD/IPD, but not for prescription/at-home use.
   4. Tramadol is preferred due to easy access (caution seizure d/o): 100mg twice daily to q6hr (max 400mg/day).
   5. Remember to prescribe stool softener and/or laxative with opioid prescription

3. Other medications:

   1. Amytriptyline – Low dose (25-50mg qHS) has good benefit in Cambodia for neurogenic pain, anxiety, and sleep disorders; higher doses (or Fluoxetine) can be used for major depression
   2. Diazepam – 2.5-5mg qHS or q4-6hr can help in palliative care for sleep
   3. Prednisone – Excellent adjunct in certain pain/inflammation control situations, such as oropharyngeal cancer with secretions/obstruction, GI tract cancers; consider adjunct PPI (omeprazole) and Calcium+Vit D for long term use
   4. Docusate – 100mg stool softener (must be imported)
   5. Bisacodyl – 5mg laxative (cheapest option; readily available)
   6. Ensure/Nutrimama – consider nutritional/caloric supplementation as indicated; 1 large can is 10USD (patient must pay unless sponsor agrees to pay)

4. Sharing a “Bad News” Diagnosis:

   In Cambodia, as in many Asian contexts, families are often reluctant to tell their loved one a “bad news” diagnosis, believing that knowledge of the diagnosis will precipitate depression and death. At MMC, we typically break bad news to a close family member first, then explain that it is usually best to tell a patient his/her diagnosis to help him/her prepare for death, and that this knowledge will not cause the disease to progress quicker.

5. Follow-Up:

   1. Palliative meds are often many in number and type; 1 month follow up is best to ensure they are optimized.
   2. Ask the family in advance to inform MMC and bring back unused medications if their loved one passes away, if it’s not too inconvenient.
   3. If a patient dies at MMC, arrange for ambulance to transport back to home (transport of a deceased person is expensive; discuss with sponsor). A death certificate should also be written in English on MMC letterhead (time/date and cause of death).